The aim of this document is to provide an orderly and systematic approach towards the history of addiction treatment in Portugal over the past five decades (1958-2014). It contains a rigorous and detailed compilation of events relating to the sector's emergence and development based on data from different sources and a substantial amount of scattered information that is not easy to understand even for specialists although laymen are also able to express their critical views, based on published facts.

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Evolution of the Portuguese addiction treatment system

More than 90 supervised injection services (SIS) operate globally, most within eight European countries, one in Australia, and two in Vancouver, Canada. SIS are legally sanctioned spaces where people can inject illegal drugs, typically heroin or cocaine, under the supervision of trained health staff and without fear of prosecution. These services allow safer injection, are associated with decreased overdoses, facilitate referrals for drug treatment, and benefit public order. In response to the increase in opioid use and associated harms, activists and officials in Canada, the USA, Scotland, and Ireland are exploring supervised injection services, but implementation is controversial.

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Making the case for supervised injection services

With opiate use documented in over half of the countries of Africa, injecting drug use reported in most of these, and linked emerging concentrated epidemics of HIV and hepatitis C infection among people who inject drugs (PWID), there is increasing attention on the incorporation of harm reduction interventions as part of national drug policy responses in African countries. The focus of interest in relation to implementing HIV and hepatitis C prevention is contextualised by longer-standing and broader concerns linked to indicators of growing drug markets, especially of heroin in the East African countries of Kenya and Tanzania. There is a growing body of epidemiological research linking the diffusion of injecting drug use with concentrated outbreaks of HIV and hepatitis C in the region. HIV prevalence estimates among PWID in Nairobi, Kenya, for example, have ranged between 14.5% and 50%, and in Dar es Salaam, Tanzania, between 35% and 50%. While data is limited, estimates of hepatitis C prevalence among PWID in these settings appear higher still. There are few robust prevalence estimates of HIV, hepatitis C or tuberculosis among people who use drugs in West African and other Sub-Saharan African countries.

In a number of East African countries – notably Mauritius, Kenya and Tanzania – drug policies have recently been characterised by a state of adaptation, wherein multiple stakeholders – including global, international as well as local actors – have negotiated the relative merits and evidence in support of harm reduction as a measure of HIV and hepatitis C prevention. In Mauritius, the endorsement of needle and syringe programmes (NSP) and opioid substitution treatment (OST) as cornerstone HIV prevention interventions as part of national policy since 2006 has reportedly enabled these services to be considerably expanded since their introduction, including OST within prisons, to the extent that over 50% of PWID are said to be receiving OST and around 50% NSP (Republic of Mauritius, 2012). In Tanzania, NSP was introduced in 2010 and methadone-assisted drug treatment in 2011, while in Kenya, NSP was introduced in 2013, and methadone treatment in late 2014. The estimated coverage of these interventions, however, is generally below optimum. For instance, assuming the numbers of PWID in Nairobi, Kenya, range between 5031 and 10,937 (0.2–0.5% of the adult population), NSP reaches between 10% and 20% of PWID, while OST in Nairobi was reaching an estimated 400 PWID by September 2015.

Drug harms and drug policies in Sub-Saharan Africa: Implementation science and HIV epidemics

(Inter)national and local policies concerning the transportation, sale, and consumption of illicit drugs encompass a wide range of perspectives along a continuum from broad legalization to stringent prohibition. Many of us citizens assume these and other policies are composed and implemented in a rational, purposeful manner by a select group of government officials after careful consideration of all the available facts. This rational/technical model is the basis for the ‘‘evidence-based’’ turn in drug policy where some actors attempt to eliminate local values and political motives from the decisionmaking process, believing that sufficient knowledge of social problems, backed by sound research, will produce effective policies with predictable outcomes. Yet even in instances where scientific research informs decisions, local values and politics continue to define what constitutes proper ‘‘evidence’’ and how it should be applied, or ignored, in policy (Lancaster, 2014; Monaghan, 2011). Policy – encompassing both formulation and implementation – remains an unpredictable enterprise. The increasing democratization of policy engenders greater uncertainty, with more actors bringing their varied values, goals, and evidence to the process. How can we researchers and stakeholders better understand the complex environment in which policy occurs? How can we apply such knowledge to reduce uncertainty and improve the policy process? What is needed is an approach that accounts for the broad range of policy actors, structures, ideas, and technologies as they interact over time to enact policy within a continuously changing sociopolitical context.

Harm reduction as a complex adaptive system: A dynamic framework for analyzing Tanzanian policies concerning heroin use

Khat, a small flowering bush native to the Horn of Africa, is an illegal drug in most countries in Europe, Asia, and North America. It has also become Ethiopia’s largest export after coffee, valued at nearly 300 million USD in recent years (Anderson, Beckerleg, Hailu, & Klein, 2007; Csete, 2014; Zenebe, 2014). In fact, khat production has been growing steadily in Ethiopia. Over the last 15 years the amount of land devoted to khat has risen 160 percent. The total amount produced has grown even faster, rising by 246 percent, amounting to hundreds of millions of kilograms of khat annually. From just a few thousand hectares in the 1950s, khat is now grown on one quarter million hectares of land in Ethiopia by millions of farmers (Gebissa, 2008). Ethiopia is the leading producer of khat globally.

While Ethiopia’s khat trade continues to expand, a growing number of countries around the world are criminalizing its sale and consumption. At least two dozen countries have listed khat as a controlled substance. The Netherlands banned khat in 2013. In 2014, both China and the United Kingdom added khat to their list of controlled psychotropic substances (INCB, 2015). French, German, and Norwegian authorities each seized over a dozen tons of khat in 2013 (INCB, 2015). Since 2005, federal and state authorities in the United States have arrested and prosecuted dozens of individuals for trafficking khat. At a single Canadian airport, Toronto’s Pearson International, authorities report making almost daily confiscations of khat (Shephard, 2012).

Ethiopian law neither explicitly allows nor prohibits the cultivation, consumption, or sale of khat (Dessie, 2013). Yet the national economy, and in particular specific regional economies, is becoming more and more dependent upon the production and trade of an increasingly criminalized substance.

This commentary will not argue for or against khat’s legality nor will it examine the health implications of khat use. Rather, we focus upon the potential consequences of the rising prominence of khat in Ethiopia’s economy and its potential political and socioeconomic implications in Ethiopia. This commentary is divided into three parts. First, drawing primarily on Ethiopian government data complemented by previous independent surveys of khat consumption, we examine trends in production and consumption of khat in Ethiopia over the last 15 years. We then use seizure data from customs and law enforcement institutions in major importing countries in Europe and the United States to demonstrate the significant changes to policies and perceptions of khat. Lastly, we combine a review of research on the political and socioeconomic effects of the production and export of other forms of illicit narcotics to analyses of contemporary Ethiopian political dynamics to reflect on the challenges and dilemmas that the country faces as the khat trade both booms and increasingly becomes criminalized.

Legal harvest and illegal trade: Trends, challenges, and options in khat production in Ethiopia

Injecting drug use has emerged as a critical concern in the HIV epidemic in Tanzania. While HIV transmission continues to occur primarily through heterosexual intercourse, transmission via shared injecting equipment carries much higher risk per exposure, making it imperative to reach people who inject drugs (PWID) with prevention and treatment services (Metzger & Zhang, 2010; Sullivan, Metzger, Fudala, & Fiellin, 2005). Port cities along the coast of East Africa have been involved in heroin trade routes between countries that supply in the Middle East and consumer markets in Europe and North America since at least the mid-1980s (Ross, McCurdy, Kilonzo, Williams, & Leshabari, 2008). However, a recent surge in the availability of strong, cheap heroin to urban populations has contributed to growth in injecting drug use in Dar es Salaam (McCurdy, Williams, Kilonzo, Ross, & Leshabari, 2005; McCurdy, Ross, Kilonzo, Leshabari, & Williams, 2006; UNODC, 2013). Easy access to heroin combined with myriad social and economic forces, such as rapid urban migration, lack of employment for youth, and limited mental health care, have further contributed to a rise in injecting drug use (Acuda, Othieno, Obondo, & Crome, 2011; McCurdy et al., 2005). The Tanzania Drug Control Commission estimates that 50,000 people inject drugs nationally (TDCC, 2010). Women’s participation in sex work to fund drug use raises the chance of PWID to act as a bridge population, potentially reversing downward trends in HIV incidence and fueling new infections (Bruce, 2010).

In Dar es Salaam, HIV prevalence in PWID has reached crisis proportions. Research estimates that 42% to 50% of PWID in Dar es Salaam are living with HIV (Ross et al., 2008; Williams et al., 2007, 2009), compared to an estimated 6.9% prevalence in the general urban population (Tanzania Commission for AIDS (TACAIDS), Zanzibar AIDS Commission (ZAC), National Bureau of Statistics (NBS), Office ofthe Chief Government Statistician, ICF International (ICF), 2013). Economic and social inequities create heightened vulnerability in women who inject drugs (WWID), who are more likely to be homeless and experience abuse than their male counterparts (McCurdy, Ross, Williams, Kilonzo, & Lesabari, 2010; Williams et al., 2007). Gendered risk-taking behavior, such as sex work and sharing equipment with other women in communal settings, contributes to a higher burden of HIV disease among women (McCurdy et al., 2010; Williams et al., 2007). In WWID in Dar es Salaam, HIV prevalence is estimated at 71% (Nyandindi et al., 2013).

Generating trust: Programmatic strategies to reach women who inject drugs with harm reduction services in Dar es Salaam, Tanzania

In West Africa, institutional weakness due to decades of political conflict has led to a worrying growth of cocaine and other drug trafficking. Local consumption has also dramatically increased, though the real extent of illicit drug use remains unknown. While efforts to address the problem have mostly focused on arrests of users and petty drug dealers, very few investments have been made in treatment and harm reduction services (WACD, 2014).

Yet drug use poses significant public health risks. Globally, injecting drug users (IDU) are disproportionately infected with HIV, with incidence estimated to be up to 22 times greater than in the general population (Mathers et al., 2008). Increased HIV prevalence is also reported in non-injecting drug users (NIDU), especially because of increased sexual risk behaviors, and overlapping social and sexual networks with IDU (Strathdee & Stockman, 2010). The small amount of data available in West Africa reports higher HIV rates in People who use drugs (PWUD) than in the general population (5.2% in Senegal, and between 3% and 9.3% in Nigeria) (Eluwa, Strathdee, Adebayo, Ahonsi, & Adebajo, 2013; Lepreˆtre et al., 2015). PWUD also remain disproportionately affected by viral hepatitis B and C (HBV, HCV), and syphilis (Coffin et al., 2010; Nelson et al., 2011). In addition, drug use is associated with a number of factors that together contribute to higher risks of tuberculosis (TB), including direct detrimental effect on the immune system, use of tobacco, homelessness, or repeated incarcerations (Deiss, Rodwell, & Garfein, 2009).

With a HIV prevalence of 3.7% in the general population, Ivory Coast is one of the most affected countries of West Africa (DHS, 2013). Abidjan, the main city, shows even higher rates, with an HIV prevalence estimated at 5.1% (DHS, 2013). The smoking of heroin ‘‘Pao’’ and crack cocaine ‘‘Yo’’ is very common in Abidjan, taking place most of the time in ‘‘fumoirs’’, which are insalubrious and crowded spaces dispersed within urban slums. Heroin is mainly used in a rolled cigarette of cannabis, whereas crack cocaine is smoked using handmade pipes ‘‘Zeb’’. Other, less frequent, consumption patterns are observed, such as chasing the dragon, snorting cocaine, or oral consumption of psychotropic pharmaceutical drugs (amphetamine pills known as ‘‘Bleu bleu’’, clonazepam ‘‘Rivo’’, barbiturate ‘‘sekou toure´’’ and different ephedrine combinations). Injecting drug use exists, but is uncommon and deprecated by Ivorian PWUD.

Ivorian authorities are determined to develop a public health approach adapted to populations at high risk of HIV. They already work closely with sex workers (SW) and men having sex with men (MSM), who face alarmingly high HIV prevalence rates: 26.6% in female SW (Vuylsteke et al., 2012a) and 50% in male SW (Vuylsteke et al., 2012b), and 18% in MSM (Hakim et al., 2015). However, PWUD’s health needs are barely known, and very few health organizations are currently working with this population. Our study aimed to collect reliable data on HIV, TB, viral hepatitis, and syphilis among highly vulnerable PWUD in Abidjan.

Prevalence and risk factors associated with HIV and tuberculosis in people who use drugs in Abidjan, Ivory Coast

International agencies have viewed West Africa as a major player in the global trade in cocaine and heroin and in efforts to control that trade. During the last 10 years there have been media and official reports of escalating arrests of West African drug smugglers, large-scale seizures and concerns about narco-states in the subregion (El Pais, 2009; New York Times, 2010; Observer, 2008; UNODC, 2008). It has been claimed that after decades of the subregion’s insignificant role in the global trade and its control, a substantial share of the drugs available in Western consumer markets transit through West Africa today and are increasingly used there as well. The head of the UN Office on Drugs and Crime (UNODC) stated in 2008.

Let’s be frank: Africa in general, never faced a drug problem – whether we speak about production, trafficking or consumption. Now the threat is there, on all these fronts (Costa, 2008).

By the end of the decade, increasing concern led to depictions of WestAfrica as the ‘coke coast’ andstates suchasGuinea-Bissaucame to be labelled as ‘narco-states’, collapsing under the ‘invisible tide’ of drug trafficking and use (Cockayne & Williams, 2009; ICG, 2008; Vernaschi, 2010). International experts were certain aboutthe evergrowing magnitude of West Africa’s role in the international drug trade. The head ofthe UNODC argued, ‘I haveno doubt we’re going to see production [of cocaine]’ (Costa cited in Kirschke, 2008). Such dramatic claims about West Africa’s drug markets – many of them based on little evidence – have helped to attract public and donor attention to Africa’s drug problems. However, they have also hindered a better understanding of drug trends and policies in the subregion, as they describe West Africa’s drug problems as largely driven by external factors and states in the subregion as too weak, porous and unprepared to withstand this external threat (Cockayne & Williams, 2009; ICG, 2008; UNODC, 2008; Vernaschi, 2010). This article assesses and challenges some of these depictions with a case study of the recent history of drug control in Nigeria – one of West Africa’s most notorious ‘drug hubs’ that attracted attention long before the current concerns with cocaine trafficking in the subregion and a country now hailed as a drug policy model by international experts. In contrast to media and official depictions and by building on the limited drug policy research available on Africa (Bernstein, 1999; Klein, 1999; Obot, 2004), it aims to provide a rare empirically based analysis of the drug policy making and implementation process in West Africa.

The article begins by reconstructing dominant narratives of Nigeria’s drug control, while the subsequent parts assess the political dynamics hidden by these narratives, drawing on an historically grounded and constructivist approach to analysing policy. First, rather than simply being driven by drug-related trends, drug control followed a broader institutional process of exclusion, typical under periods of military rule in West Africa and continuing into democratic Nigeria after 1999. Second and linked to this process, the Nigerian state – rather than being too ‘weak’ to react – showed a strong preference for repressive drug control sidelining the policy alternatives propagated by health officials. Finally, Nigerian drug officials, particularly in the National Drug Law Enforcement Agency (NDLEA), have also begun to externalise their domestic political conflicts over resources and ideas in the last 15 years by drawing in international drug agencies – mostly as a means to prevent policy change and reform. In essence, drug control over the last 25 years has been driven more by concerns over state power rather than Nigeria’s drug problems – evidence of which has been sparse since the country’s earliest drug policies.

The politics of drug control in Nigeria: Exclusion, repression and obstacles to policy change

Opiate use has been documented in 36 countries in Africa, with its prevalence ranging from an estimated 2.3% of the adult population in Seychelles, to 1% in Mauritius, and 0.3% in Kenya (Ministry of Health of Seychelles, 2011; UNODC, 2014). Injecting drug use has been reported in 28 African countries, with increasing evidence of linked HIV epidemics (Bouscalliou, Evanno, Proute, Inwole, & Kanran, 2016; Kurth et al., 2015; Lepretres et al., 2015; Matiko et al., 2014; Nyandindi et al., 2014; Scheibe et al., 2016; Eluwa et al. 2013). Two scenarios characterize the diffusion of HIV among people who inject drugs (PWID) in the Sub-Saharan African region: there are countries, such as Kenya and Tanzania, that have moved from a long-established generalized HIV epidemic to a recent mixed epidemic with high HIV prevalence among key populations, including PWID; and there are concentrated HIV epidemics among PWIDs emerging in low HIV prevalence countries, such as Mauritius, Seychelles and Zanzibar.

There is now wide consensus in the region that the adoption of the comprehensive package of nine evidence-informed interventions recommended by United Nations (WHO, UNODC and UNAIDS, 2012), and the United States President’s Emergency Fund for AIDS Relief (PEPFAR) tenth intervention, namely outreach, can help significantly reduce new HIV and hepatitis infections among PWID and their sexual partners. The global evidence in support of combination HIV prevention for PWID is compelling (Degenhardt et al., 2010; MacArthur, Minozzi, & Martin, 2012), and this has framed initiatives supported by PEPFAR in the region since 2010 towards fostering policy change supportive of the development of harm reduction. The combination of interventions promoted includes mutually reinforcing biomedical, behavioural, and structural interventions, which are not only evidenceinformed but rights-based as well as community-owned. Countries have begun to endorse and develop a package of HIV prevention intervention for PWIDs, including to varying extent, medically assisted therapies for treating opiate use and addiction, low threshold access to antiretroviral HIV treatment, needle and syringe distribution and exchange, sexual behaviour change communication, and community outreach. There is also a need for structural interventions to address critical social, legal, political, and environmental enablers of HIV risk.

Policy change towards implementing harm reduction in Sub-Saharan Africa

Wherever there are significant numbers of people injecting in public, there is a clear need for supervised injecting facilities.

The introduction of Supervised Injecting Facilities in Scotland is one of three recommendations in a report published by Kirsten Horsburgh, National Naloxone Coordinator at Scottish Drugs Forum, following her Winston Churchill Memorial Trust Travel Fellowship to Australia.

Kirsten was awarded the 6 week Fellowship to research strategies adopted in Australia to reduce drug-related deaths. During this trip she spent 2 weeks in the Medically Supervised Injecting Centre (MSIC) in the Kings Cross area of Sydney to gather learning from this service to inform key stakeholders and decision-makers in Scotland.

Drug-related deaths in the UK are at an all time high. In Scotland, these deaths are among the highest in Europe, per head of population. 613 people lost their lives to accidental and preventable overdoses in 2014.

Reducing drug related deaths in Scotland

Study rationale and methods In recent years signals from both formal and informal monitoring sources based in a number of countries have been flagging critical new developments within Europe’s MDMA/ecstasy market. These include signs of increased MDMA production and availability, the opening of new online markets, reports of increased use, the issuing of alerts on both high-dose MDMA tablets and adulterated tablets, and evidence of low but potentially rising numbers of MDMA-related hospital admissions, and even deaths in some countries.

In order to investigate these changes and developments in the supply and demand of one of Europe’s more established illicit drugs, a targeted ‘trendspotter’ study was initiated by the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and carried out between August and October 2015. The primary aim of the study was to increase understanding of recent changes in the MDMA market in Europe. More specifically, the study set out to explore: levels and patterns of MDMA use; the MDMA market including production, supply and product availability; MDMA-related harms and deaths; and implications for law enforcement, health and social responses.

The study commenced with a phase of data collection and a literature review undertaken by a team drawn together from different sectors within the EMCDDA, and culminated in an expert meeting in Lisbon on 22–23 October 2015. Fourteen experts attended the meeting, sharing their experiences and contributing to an in-depth analysis of the topic, providing insights from drug research and monitoring, wastewater analysis, law enforcement and health perspectives.

The trendspotter study methodology incorporates a range of different investigative approaches and data collection from multiple sources. This study included two expert web surveys, a review of the international literature and available monitoring data, 15 expert presentations and findings from three facilitated working groups. Analysis was based on triangulation of these information sources, with a view to providing as complete and verified a picture as possible. The combination of routine and survey data with key informant reports and law enforcement intelligence provided a rich and in-depth view of a rapidly changing phenomenon. This report summarises the study findings and conclusions. Where results are literaturebased, references are cited, otherwise findings are based on EMCDDA monitoring and the qualitative sources described above.

Recent changes in Europe’s MDMA/ecstasy market

Desde que a Convenção Única sobre Entorpecentes foi adotada, criando a estrutura para o sistema global de controle de drogas, há uma evidência crescente de que a abordagem da “Guerra às Drogas” levou às sérias consequências negativas 2 . Como resposta, o debate sobre a política de drogas internacional tem incorporado de forma crescente a ideia de uma abordagem de saúde mais equilibrada. Na ‘Declaração Ministerial Conjunta’ das Nações Unidas sobre drogas de 2014, estados membros chegaram a um consenso de que “o problema mundial das drogas ... demanda uma abordagem integrada, multidisciplinar, equilibrada e de reforço mútuo.”3 Em abril desse ano, a Sessão Especial da Assembleia Geral das Nações Unidas (UNGASS) sobre o problema mundial das drogas incluirá uma mesa redonda dedicada às “Drogas e à Saúde”.

Ao nível regional, o Plano de Ação para o Controle de Drogas da União Africana (2013- 2017), inclui serviços sociais e de saúde como um dos quatro resultados prioritários. 5 Recentemente, a Posição Comum Africana para a UNGASS enuncia que uma abordagem mais equilibrada é necessária para focar na saúde e nos direitos humanos de pessoas que usam drogas”.6 Essa narrativa tem sido usada de forma crescente por múltiplos estados.

Ao mesmo tempo que essa mudança de tom é bem-vinda, é crucial que o conceito de políticas de drogas equilibradas e baseadas em saúde não se tornem frases diplomáticas vazias. Essa retórica tem de ser combinada com uma mudança real sobre como reagimos em campo na África e no resto do mundo. Portanto, essa nota para advocacia busca elaborar como seria a prática de uma abordagem de saúde na África, e explora cinco áreas específicas que precisam ser urgentemente tratadas pelos governos.

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